COVID-19 vaccine, polyethylene glycol and polysorbate information
Question:
11/18/2021
My question is regarding a 46-year-old health care worker with a history of anaphylaxis to taxol and taxotere (10 years ago) who had hives, flushing, dyspnea, vomiting and diarrhea within minutes of receiving her second COVID-19 mRNA vaccine. She had received the first vaccine without any issues. Shortly after receiving the first vaccine, she actually received a message from the local University Hospital pharmacy (where she received breast cancer treatment 10 years prior) warning her that she should observe for anaphylaxis to the vaccine due to her history of anaphylaxis with taxol and also taxotere which was tried as an alternative to taxol after the taxol anaphylaxis.
Because she had had the first vaccine without problems, she proceeded to receive the second dose, and had the reaction within minutes of this dose. In my research, I found that taxotere contains polysorbate, but taxol does not (contains polyoxyethylated castor oil). I would definitely not have been aware that polyoxyethylated castor oil is synonymous with polyethylene glycol castor oil.
My first question is: are you aware of any resources to help allergists identify synonyms for polysorbate and polyethylene glycol so that we may determine from medication ingredient descriptions which medications contain PEG/polysorbate or its' derivatives?
My second question is: patient has actually taken p.o. miralax regularly since both the taxol/taxotere reaction and also since the COVID-19 vaccine reaction. I'm assuming that some patients have anaphylaxis to this substance only when it is injected or infused?
My third question: polyoxyethylated castor oil is not related to octylphenol ethoxylate, that is contained in many other vaccines, correct?
My fourth question is: are you aware of a good resource for allergists detailing which injectible/oral/infusion medications contain polyethylene glycol/polysorbate so that we may advise patients?
Finally, she wants to receive a "booster" dose at some point. Am I correct in that there would not be a vaccine currently approved/available that would be safe for her to have, due to the fact that the J&J vaccine also contains polysorbate 80?
Answer:
I am extremely grateful to Dr John Kelso for responding to your questions.
My first question is: are you aware of any resources to help allergists identify synonyms for polysorbate and polyethylene glycol so that we may determine from medication ingredient descriptions which medications contain PEG/polysorbate or its' derivatives?
1. Stone CA, Jr., Liu Y, Relling MV, et al. Immediate Hypersensitivity to Polyethylene Glycols and Polysorbates: More Common Than We Have Recognized. The Journal of Allergy and Clinical Immunology: In Practice 2019;7(5):1533-1540.e8. https://pubmed.ncbi.nlm.nih.gov/30557713/
2. Wenande E, Garvey LH. Immediate-type hypersensitivity to polyethylene glycols: a review. Clinical & Experimental Allergy 2016;46(7):907-922. https://pubmed.ncbi.nlm.nih.gov/27196817/
My second question is: patient has actually taken p.o. miralax regularly since both the taxol/taxotere reaction and also since the COVID vaccine reaction. I'm assuming that some patients have anaphylaxis to this substance only when it is injected or infused?
While it is possible that the patient reacted to PEG only when it was injected and not ingested as is the case with some gelatin allergic patients, generally the tolerance of a large amount of ingested PEG would argue against the tiny amount of PEG in the vaccine (0.05 mg) as being the cause of the reaction. The mechanism whereby PEG might cause a mast cell mediated systemic reaction include not only IgE-mediated reactions but also complement activation related pseudo-allergy (CARPA), although neither has been definitively proven to be the cause of mRNA COVID vaccine reactions, again because the amount of PEG in the vaccine may not be sufficient to provoke such a reaction even in a susceptible patient.
My third question: polyoxyethylated castor oil is not related to octylphenol ethoxylate, that is contained in many other vaccines, correct?
This is also an ethylene oxide derivative, of which there are many, with varying levels of potential cross-reactivity.
My fourth question is: are you aware of a good resource for allergists detailing which injectible/oral/infusion medications contain polyethylene glycol/polysorbate so that we may advise patients?
Please see references above.
Finally, she wants to receive a "booster" dose at some point. Am I correct in that there would not be a vaccine currently approved/available that would be safe for her to have, due to the fact that the J&J vaccine also contains polysorbate 80?
All COVID-19 vaccines in the pipeline contain polysorbates. This patient's reaction may or may not have been related to the PEG in the vaccine. Many patients who have an immediate reaction to a COVID vaccine dose tolerate subsequent doses for reasons which are unclear. When she is due for a booster, I would recommend skin testing with the vaccine itself prick full strength and if negative ID 1:100. If the skin tests are negative, I would administer the vaccine is a single dose and observe the patient for one hour. If the skin tests are positive, you could consider administering the vaccine in graded doses. You could also consider offering the J&J vaccine as a booster, also with skin testing prior. After the skin tests are completed, antihistamine pretreatment prior to vaccination could be helpful.
Jacqueline A. Pongracic, MD, FAAAAI